A Weekly Lament about the Public Understanding of Science

Suicide and Self-Identity

This is a departure from my normal routine, but I wanted to write about this issue. Perhaps I could claim it has something to do with Social Science writing. In any event, I will return to my regular form next week

There has been quite a lot said about suicide in the wake of the death of Robin Williams. Besides the outpouring of appreciation and love for the man, the commentary about the suicide has run the gamut from the judgment that it is good that Genie is now free to the assessment that Williams was wrong for taking his own life. Now, a ever-growing number of people has begun to say we shouldn’t say that suicide is ok in any way for fear of “suicide contagion,” the purported phenomenon of suicides spiking when a well-publicized suicide occurs.

Aside from the “Genie, you’re free” contingent, most everyone else assumes that suicide is bad no matter what. That’s what I’d like to take up here. (As an aside, Williams himself once made a joke about calling a suicide hotline and getting the response, “Hey, life isn’t for everyone.”)

There are lots of ways to commit suicide. Many of the most famous are what I’d call “surprise-attack” suicides—suicides that surprise almost everyone the victim knows. Maybe Williams’s death was one of these, maybe not. I don’t have any familiarity with such suicides (although my wife does) so I will not discuss them.

All of my immediate family members who have died committed suicide. And it was great…

My mother was the first. She was diagnosed with lung cancer in 1988. She had smoked for most of her adult life, but had quit almost 15 years earlier. When she found out the nature of her cancer, she chose to forego everything but palliative care. She died in January of 1991, having only used pain medicines and some intravenous fluid. She made the decision that she would not trade quality of life for length of life, and I respected her greatly for this. My father, a pathologist, was distraught at losing any time with her, but he abided by her wishes, although he tried to convince her to try chemo.

I know many of you would not categorize this as suicide, but it was a conscious decision to shorten her life (as certainly as if she had tried to overdose—but that doesn’t always work) because she was dissatisfied with her prospects.

My father died much more quickly from lung cancer (he had stopped smoking when my mother did) and he also refused treatment. This was in 1999, and while I hated to see him go, I respected his decision as well.

But the real story behind this essay involves the death of my brother. Josh was 30 when he had a brain stem stroke in 1983. The stroke occurred on April Fool’s Day during my senior year of college. I remember my girlfriend calling out of her 2nd floor window for me to come to the phone like it happened an hour ago.

The stroke, which is extraordinarily rare, left Josh with “locked-in syndrome.” If you’ve read The Diving Bell and the Butterfly or seen the movie, you know all about it. If not, it is what happens when you are cognitively unimpaired but almost completely paralyzed. Post stroke, Josh could only control his eyelids. He was on a ventilator, slightly hearing-impaired and unable to point his eyes at the same spot. We communicated with him by reciting the alphabet until he blinked and then writing that letter on a piece of paper and going on. It took a long time for him to “say” anything.

Over time, things got a little better. He eventually got off the ventilator, but was never able to speak. All the rest of his impairments remained, but after several months, he did regain the ability to move 2 fingers on his left hand. With the help of two amazing and talented friends, we devised a telegraph key that eventually let him get up to about 40 words a minute in communication.

Josh was a radiology resident at UVA when he had his stroke. He was outgoing and, to many people, funny and charming. He had a fiancé and his future was bright. In an instant, he became a man who needed around-the-clock care, including hourly turning on the bed and care for the most basic biological functions. For the next 13 years, he was cared for at home by my family, mainly by my mother and father and the nurses they hired to cover the hours during which they needed to sleep and work.

For the next 13 years, my brother decided life was worth living, despite the pain he was usually in and the isolation he felt. He discussed it in an interview with a local newspaper reporter. But eventually he changed his mind in 1996. And my father did what I think anyone would do—he made it possible for him to commit suicide. Josh could never have held a gun, let alone pulled the trigger. He could not swallow anything, including pills or liquids (he had a feeding tube). He could not get to the ledge of a building, tie a noose, drive a car off a cliff or anything of the sort. If Josh was going to die, he needed help. Otherwise, given his level of care, he would plausibly lived another 40 or more years of a life he did not want to live.

My father helped my brother. A friend of his who is an attorney told us it was legally safer to let him starve to death than to take any direct action to shorten his life. He also knew that we could let Josh lie on his back for a long enough time to induce pneumonia and then withhold antibiotics. My father decided that both of those options were barbaric.

Friends told him it was a sin to help and that Josh would surely go to hell if he proceeded. Of course, they only knew about what was about to happen because we had told them. My father had decided that Josh would not surprise anyone by dying. In the days before his death, he heard from and communicated with everyone that mattered to him, including one friend on a satellite phone from, literally, darkest Africa. Josh died surrounded by loved ones, in control and unafraid. And he committed suicide, in every sense of the word. And my father helped him.

I cannot imagine choosing another course of action.

It may be that a difference between these cases and the case of Robin Williams is that the cases I describe seem untreatable or nearly so. It may seem easier to accept suicide in cases where the victims have no real hope of recovery or only of lifespan extension for some time only after suffering through painful treatment. In Williams’s case, it might seem to some people that there are treatments available for depression and so his suicide is somehow worse. Some evidence that this is what is going on in the public discussion comes from the fact that when the family revealed that Williams was also battling Parkinson’s disease, some previously critical voices grew more understanding.

There are treatments for depression, both talk-based and pharmaceutical, but some depression is treatment-resistant. My uncle had a case a severe depression that returned after every type of treatment, including ECT. I’ll just assume that Williams had access to all sorts of therapies and found that none of them worked. Or it could be that some drug treatments took away the depression but also took away parts of his personality or self that he considered essential. Oliver Sachs wrote of a patient who called himself Witty, Ticcy Ray who was resistant to treatment for Tourette’s Syndrome, which can be pretty incapacitating due to muscular tics, because under the influence of the effective medication, the patient didn’t feel like himself. Specifically, he wasn’t funny anymore. So, for a while at least, he chose the disease and his wit over the cessation of symptoms and no wit. Like Ray, perhaps Robin Williams chose not to use drugs that would level out his depression but would also rob him of his wit. Thinking of Robin Williams without his wit is just thinking of someone else who looks like Robin Williams. If this is the sort of choice Williams faced, I, for one, can understand choosing the symptoms and the wit and someday being overcome by the symptoms.

In The Diving Bell and the Butterfly, Jean-Dominique Bauby writes that given the amount of time it took him to communicate, he could no longer engage in the witty banter he was known for. By the time he “said” what he was thinking, the conversation had moved on and no one knew what he was referring to. He writes that after a while, he just stopped trying to “say” the funny things he thought of and that, after a longer while, he just stopped thinking of funny things to say. He tells a tale of a person who is witnessing his own self fade away.

Now I don’t know what killed Bauby. But I know he died within two days of the publication of his book. According to the record, he died of pneumonia, one of the passive options we were presented with for Josh. Perhaps his loved ones supported his choice, if he made such a choice, not to continue a life he could not recognize as his own anymore. I know that I would support that choice.

Were the disposal of human life so much reserved as the peculiar province of the almighty that it were an encroachment of his right for men to dispose of their own lives; it would be equally criminal to act for the preservation of life as for its destruction. If I turn aside a stone, which is falling upon my head, I disturb the course of nature, and I invade the peculiar province of the almighty, by lengthening out my life, beyond the period which by the general laws of matter and motion he had assigned to it.